Epidural lipomatosis: the connection between high BMI and central lumbar stenosis

For some reason I've been going through a lot of lumbar MRIs recently. Some that I ordered and some that came with patients on their 1st appointments. Central stenosis seems to be the common recurrent theme in all of these patients. Central stenosis describes an anatomical situation where the canal that hosts the spinal cord and the nerves that go to the lower extremity and lower abdominal organs is narrow and potentially causing neurological compression.

The compression can come from a variety of sources including disc herniation's crowding the front of the canal, posterior disc margin bony spurs, congenital narrow canal, degenerative changes that narrowed the vertical dimension, thickening of the posterior canal lining ligaments causing crowding into the posterior canal, chronic posterior slippage of a vertebra (retrolisthesis). The last one on the list is a problem that we are seeing at an increasing frequency on MRI reports called epidural lipomatosis. It describes a phenomenon whereby the normal fat pads on the outside of the spinal cord lining become enlarged and crowd the nerve bundles.

I recently had a very enlightening conversation with 2 seasoned spine radiologist about this phenomenon. For a while this was thought to be an idiopathic finding meaning we did not know what was causing it, however there is very strong new research suggesting that epidural lipomatosis is part of metabolic syndrome associated with high BMI, abnormal carbohydrate and lipid metabolism. The type of fat that makes up the fat pad is very similar to visceral fat, and responds to the same signaling to grow or recede. My long-standing radiologist stated that he has seen a few cases of patient going on very stringent weight loss diets with subsequent follow-up MRIs showing almost complete resolution of the epidural lipomatosis and significant resolution of the central stenosis.

This blog is not meant to beat up on people who already struggling with high BMI and metabolic syndrome. But it can be an encouragement for some people who are wondering if dropping their weight in improving the body composition will have any impact on some of their chronic referred spinal pain. The answer is that it will. Let that be an encouragement to stay the course or to take on the process in the 1st place.

auricular and occipital neuralgia

There is often a lot of confusion about pain in the back of the head. Is it referred pain? Is it a headache? And to some extent in depends on who you ask, but really should look again a little more closely at the anatomy of the Innovation of the back of the head to better distinguish where the problem is, in order to have a chance at resolving the problem.

There are a total of four peripheral nerves that cover the back of the head from the midline to just above the ear: the third occipital nerve, very close to the midline, and not often a big player, the greater occipital nerve, slightly lateral to the center and often an intense source of referred head pain, the less occipital nerve, slightly more lateral, in the auricular nerve, just behind the ear and often feeling like it's deep in the bone.

All of the four nerves that cover the back of the head or originate from the upper cervical spine from C3 all the way to the occiput. What is less understood is the fact that they have to exit through a variety of myofascial paths, including fairly lateral behind the big SCM muscle. As a result, posterior head pain can be referred from the spinal articulations themselves as well as a variety of myofascial structures. Differential diagnosis of posterior head pain requires a careful examination of the structures from the spine all the way to the exit points at the nuchal line. Cervical misalignment, facet syndrome, facet degeneration, muscle spasm and muscle scoring from injuries all can be accounting for the chronic posterior head pain. It takes some detailed palpation to tease them apart. In particular I feel that a lot of the SCM muscular injuries from things like whiplash are often the source of posterior head pain but often get missed because the myofascial entrapment is likely more to decide than the referred posterior head pain.

Is chiropractic care safe for infants ?

https://pubmed.ncbi.nlm.nih.gov/25439034/

I am wrapping up the first day of our Homecoming continuing education classes and relishing our last segment of the day on pediatric chiropractic care. The office is full of new babies recently, reminding me of the privilege of serving that slice of that demographics.

When parents seek chiropractic care for their new baby for the first time, they often have questions and hesitations, especially regarding the safety of chiropractic treatments. ( sometime fueled by their medical provider, who may not be familiar with chiropractic care for infants). Prior to treating , we will spend a little time educating moms and dads about the different methods of treating an infant spine, which are quite different than those applied to adults.

Research data is also a good way to properly reassure a parent seeking care for their baby, and I have been directing them to this wonderful 2015 JMPT literature review article. The article reviews all reported pediatric adverse events to spinal manual therapies in the medical literature. The take home message is as follows:

• serious adverse events are very rare

• none of the 3 deaths reported in the last 30 years were the result of treatment by a Doctor of Chiropractic

• in all serious adverse events, there were silent serious predisposing problems ( neurological mainly)

• manual therapies consisting of high velocity manipulation combining rotation and extension of the upper neck were identified as potentially being a risk for adverse event. Chiropractors focusing on the young pediatric population use single axis adjustment with no extension and very minimal rotation.

It also important to point out to concerned parents that the risk factors of any intervention are relative to the risks factors of other interventions used to treat the same problem. In that regard, the medical alternatives to common conditions treated with chiropractic ( antibiotics for ear infections, PPI medications for reflux), carry a surprisingly high risk of serious side effects.

Are "gateway foods" as risky as "gateway drugs"?

https://www.sciencedaily.com/releases/2022/09/220907105453.htm?utm_campaign=Friday%20Favorites&utm_medium=email&_hsmi=230513745&_hsenc=p2ANqtz-__fiHLmVu7gUl3GUFjJE1MZy9ZdyOlFRCSgjUcTpuhUWYK-FzPO8JZfrZ0Dajj2tLT5KkoGxk5T4uXXP8Igq1YpDnQYw&utm_content=230513745&utm_source=hs_email

It's a delicate topic to broach because emotions often run high and the concern over the less-than-robust mental health of our teens in general often leads us to dodge important questions about habits, especially poor habits where change would be beneficial. Nutritional habits, however, have been under increasing scrutiny in light of the recent recommendation concerning the increased prevalence of severe childhood obesity, and the drastic recommendation to make even preteen children eligible for weight loss drugs and bariatric surgery.

Current stats indicate that 20% of US children are in the moderate to severe obesity category. That's a whopping one in five children. This does not include the remainder of children may be in the mild obesity, with the BMI between 23 and 30, which is still alarming in terms of health outcomes. The medical profession now is obviously raising the question of the metabolic consequences of these statistics, such as hypertension, kidney disease, etc. From a clinical perspective in my daily practice, I also see another side of this high BMI + malnutrition complex: children who have poor skeletal and soft tissue structures because of the lack of appropriate nutrients which have been displaced by empty calories; poor recovery from relatively minor injuries; chronic fatigue; and mood changes associated with nutritional deficiencies.

It's a very complicated topic to which no one can do justice in a blog entry. However I wanted to bring up this paper because it highlights an issue to which we have been desensitized. Kids, especially kids in the developing world and even more so in the US, eat a stunning amount of junk food. It has no nutrients, and it has been engineered by the food industry to be highly palatable with additives that trigger very targeted brain responses, causing children to be addicted to to these foods. There is currently a level of tolerance to junk food in our children that is not serving them well. The idea that kids should be able to splurge, have dessert, enjoy "treat foods", is out of control. What used to be a once-in-a-while event, a couple of times a year for special occasions like birthdays, is now creeping up in the kids’ daily diet. But it's time to recognize that those foods are not as innocuous as we think they are, and they may well be "gateway foods", the equivalent of gateway drugs: foods that create levels of dependence and addiction leading to a vicious cycle of increased craving and consumption.

I also recognize that this blog entry is not going to be a platform to outline a complete solution, especially for parents who struggle with the complex issues of children exposed to food influences outside the home that are hard to combat. But it is intended as an encouragement for those parents who are convinced that they should limit their kids’ access to junk food because you are doing the right thing and not overreacting. Leading scientists in the field are supporting your instinct to protect your children. I hope this article will give you some robust data to have discussions with your children, your family, and anybody else who is involved in your children's diet.

Customizable Pillow

https://luxome.com/products/layr-adjustable-pillow?variant=31902303125565

Just before COVID hit Dr. Alvarez and I were talking about live workshops we were hoping to offer (we had just finished the “pregnancy prep” and “infant basic craniosacral” classes and wanted to veer off a bit). High on the list was a workshop cheekily dubbed “pillow talk”, basically a class on selecting the right pillow for the condition and sleeping position, with an actual hands-on portion where patients could try a variety of options. Needless to say, bringing a large group of folks indoors (and sharing cheek space on the same piece of fabric) became scary overnight and we never got to complete the project

Years ago we had a working relationship with a local upholsterer who was able to custom-build pillows based on the measurements we took and would then send to her for individual patients. It was a fascinating and challenging process that involved coring out a base of frozen memory foam to make room for the head at right cervical length, then adding layers of batting and foam to the right thickness. The final product was simply amazing, but our source eventually retired and nobody wanted to take over that kind of craft. Ever since then I have been on the hunt for something similar. I have recently discovered that there are several new pillow brands on the market that offer the option of customizing the thickness and firmness of a pillow, by having the customer add and remove either internal batting layers or raw form material to adjust to their needs. Here would be one example of such a product. From what I have seen, those modifiable pillows do a decent job at allowing patients to modify the pillow for thickness, firmness, although they are lacking the ability to account for the length of the cervical spine and switch from side to back sleeping position. That being said, it may still be the best option I have yet found as a replacement for the fully custom pillows we used to order.

Metabolic Syndrome and Risk of Lumbar Discogenic Pain

https://chiro.org/Conditions/Metabolic_Syndrome_Components.shtml

The question that invariably comes up when we sit down with patients to review films demonstrating significant levels of disc degeneration, especially in the lumbar and thoracic spine, is “what causes that?” Patients seem to already understand the correlation between age and degenerative disk disease (later referred to as DDD), and of obesity. Fewer patients grasp the correlation with trauma, acute and repetitive. And fewer yet understand a more nuanced reason: the disc is at the mercy of poor body chemistry. Spinal discs are soft tissue structures that have a limited blood supply to bring in nutrients needed for routine maintenance and injury repair. If the body “soup” is of poor quality (inflammation, nutrient deficit, free radicals) the disc is not going to meet needs for self repair and will deteriorate at a faster rate than one would expect for one of that age and cumulative trauma load.

Of special interest is the impact of impaired glucose tolerance (a.k.a., diabetes or pre-diabetes) on disc degeneration, even independent of excess weight. This is sobering news in the context of US health stats predicting a rate of adult diabetes close to 30% by 2030 if we do not reverse course on some of our health habits. I have seen this time and time again in practice. Metabolically driven DDD is quite real, and quite profoundly complicates treatment. Remember that diabetes is largely preventable and do your part.

Headaches and the hidden sources of MSG

As usual it takes a couple cases back to back to throw me into writing an overdue blog. In this case, some mysterious atypical migraines for which the patient could not figure out any trigger.

There is a lot of confusion about MSG and the reactions that people can get from it.

First, probably helpful to review what MSG actually is and what it does. MSG stands for monosodium glutamate. It's both a naturally occurring substance of food aging and fermenting, as well as a strong chemical additive that is added to a large variety of foods to enhance taste, palatability, and the desire to eat more processed foods. The glutamate part is also an excitatory neurotransmitter, which when combined to the monosodium bit makes it very more apt to cross the blood brain barrier and dump into your central nervous system where it will act as a strong stimulus to brain cell electrical firing.

Patients can have varying degrees of sensitivity to MSG. For some people, they might not know the difference if they have a small amount and have no particular sensitivity. For other patients, there reaction ranges from mild to severe. Patients who are more likely to have a severe reaction to MSG are people who have blood brain barrier weakness, such as patients with previous concussion, certain medications, and certain type of chronic infections and autoimmune tendencies. For those people, the MSG can cross the blood brain barrier, create a sort of electrical storm in the brain that drains the battery of brain cells, and lead to widespread random brain activities that can manifest as migraine headaches, with a lot of other unusual symptoms such as pain, tingling in their body, and a lot of autonomic symptoms such as nausea and G.I. upset. For some people the MSG induced symptoms can last a few days.

MSG actually does occur in very small amounts in natural foods that have been aged and fermented in particular. However that is rarely the culprit. MSG used as a food additive occurs in much larger amounts than what people would typically see in unaltered foods.

Where the real problem comes in is that MSG is often not labeled as MSG in food. Below is a good reference website that lists all the names under which MSG can be labeled, making it a real challenge for patients to pinpoint MSG as 1 of the triggers to their headaches. I have several patients who have printed the list in a wallet size cards that they carry with them when they shop. To give you an example of common MSG additives:

• Autolyzed yeast

• Autolyzed yeast protein

• Carrageenan

• Pectin

• Sodium caseinate

• Soy isolate

• Soy sauce

• Textured protein

• Vegetable extract

• Yeast extract

• Yeast food

https://www.prevention.com/food-nutrition/a20472934/other-names-for-msg/

SITTING IS THE NEW SMOKING

https://jamanetwork.com/journals/jamacardiology/article-abstract/2793521

There are so many important topics to try to keep up in the blogs that I haven't talked about this one for a while and it's overdue. Especially in a post-pandemic area were still many people have remained working from home part or full time, and even the small amount of physical activity involved in getting in the vehicle and commuting to a workspace has been eliminated for some folks.

The data on the harmful impact of prolonged sitting keeps mounting, and its metrics on adverse health outcomes is becoming increasingly measurable, in the same way that we can measure adverse impact of smoking in terms of daily cigarettes. This most recent study published by JAMA puts some numbers on the problem and they are sobering. For the people who pride themselves of not smoking, remember that if you consistently sit eight hours a day without some balancing physical activity outside of that, you are no better off than someone puffing a pack a day.

There are a few simple strategies that you can work on to mitigate the impact of Fort sitting.

– Whenever possible, consider having a sit stand workstation. The availability of inexpensive desktop retrofits is becoming widely available. Many employers are also honoring requests of employees to retrofit their workstation with us it's an option if not alright available. In the end, for a few hundred dollars you can probably make it happen even if your employer is not cooperating. Your health is on the line. You do not need to be standing your whole workday but try to aim for 1/3 to 1/2 of the total time

– Whenever take frequent standing and walking breaks. To keep yourselves accountable, use a fitness tracker to see what your total sitting time is. Ideally you want to be below four hours of workday.

– If you are in a situation where avoiding prolonged eight hour workday sitting is impossible, make sure to make up with it with vigorous balancing physical activity outside of that timeframe. Walking, higher intensity aerobic exercise. Prolonged sitting is especially associated with poor cardiovascular outcome, possibly because of the stress it physically puts on our arterial system.